Meeting Challenges in Dual Diagnosis of Substance Abuse and Mental Disorders - Thesis Example

Mental Health Services: Meeting Challenges In Dual Diagnosis Of Substance Abuse And Mental Disorders Abstract Dual diagnosis is defined as coexisting serious mental illnesses and substance misuse problems in an individual. The needs of these individuals are complex and arise from the comorbid nature of both these problems. There is a paucity of research in this area in the background of the United Kingdom; however, research from the United States indicates that the effectiveness of the services to these individuals can be enhanced with a better understanding of their problem. Based on available research, a literature review within a methodological framework has been done in this assignment. This review demonstrates that there is a need for a mental health service framework for the efficient care of these clients. Depending on recommendations from evidence, the National Mental Health Services Framework has a programme which integrates mental illness with substance abuse services, existing community mental health services and social services framework. However, in order to implement this framework in practice, mental health professionals must be educated and trained suitably enough to be aware of these conditions so they, in turn, can raise awareness of the clients in order to motivate them better. Introduction Substance misuse and addictive behaviour are common public health problems in the United Kingdom. The co-occurrence of psychiatric disorders with alcohol and drug use disorders is common and well-recognized. Thus there is a need for us to investigate dual diagnoses as to their reasons for co-occurrence, methods to differentiate substance abuse from psychiatric syndromes, and treatments for co morbidity. There is now an emerging consensus that when the clinical picture is limited to a single disorder, there are chances of fewer complications (Drake & Wallach, 2000, 1126-1129).. Research has again demonstrated that co-occurring mental and substance use disorders are associated with problems among users, dependence among problem users, severity and persistence of both mental and alcohol-drug disorders, poor health, failed treatment attempts, violence, incarceration, and poverty (Essock et al, 2001, 469-476). Therefore, it would be pertinent to investigate or to find evidence whether these available mental health services are adequate enough to meet the growing needs of these individuals with dual diagnosis. In this review article, a systemic review has been proposed to be undertaken within a methodological framework, so that the evidence may be culled in order to substantiate the focus question and rationale to conduct this review. Focus Question Are mental health services fully meeting the needs of service users with dual diagnosis, illicit substance misuse and serious mental illness? Rationale The problems of dual diagnosis are further compounded by the fact that clients with dual diagnoses are difficult to assess because they are not a homogenous group. In addition, these clients often are poor historians and are noncompliant during the assessment process. It is said that after prolonged research and development, dual diagnosis mental health services for clients with severe mental illness are emerging as an area of evidence-based practice (Johnson, 1997, 205-208.). Numerous models of providing integrated treatment and services to these clients have evolved. Regarding the best practice in caring for subjects with dual diagnosis, the Department of Health (1999) has recommended a mainstream responsibility. Initially suggested by Appleby et al (2001) and later recommended by el-Guebaly (2004), there could be three main patterns of treatment that can constitute the sequence of care in these patients. These are sequential treatment, parallel treatment, and integrated treatment. This indicates there is a need to assess the available mental health services and their efficacies for people with dual diagnosis. Methodology A literature review that is approached systematically is very different from the one which is approached in a haphazard manner (Evans, 2002, 290-293). This would need development of exclusion and inclusion criteria for the review (Finfgeld, 2003, 893-904). Paterson et al. (2001) described the use of a theoretical framework to guide the development of the research question. Since this topic involves assessment of UK mental health services for patients with dual diagnoses, the areas of focus are the framework of mental health services and its implementation and adequacy. This extended literature review is based on the focus question on whether existing mental health services are fully meeting the needs of the service users with dual diagnosis, illicit substance use and coexisting serious mental illness. There are basically three concepts involved in this focus question. From the discussion in the rationale, it appears that dual diagnosis has complicated problems of its own, which are specific for the suffering individual. The second point is awareness and difficulty in diagnosis and barriers in the individuals’ procurement of service. The third concept concerns problems in policy and in implementation of services. A literature review is important at this point because it brings out evidence from existing literature for us to put into practice. Based on these, the inclusion criteria were established as follows Criteria Description Client group Clients of any age with history of dual diagnosis with no restriction on race or gender, mental health diagnosis, or substance of abuse Date Restriction Most updated information from original research articles published in the time frame of last 10 years with preference to most recent studies between 2002-2009 Geographical Restriction Although dual diagnosis is a worldwide problem, since the mental health services of UK is concerned, literature dealing with mental health services in the context of people with dual diagnosis will only be considered. However for wide reading and comparison of services and knowledge about the newer approaches, identical literature from other countries will also be consulted and referred to. Mental Health Professionals Studies dealing with mental health professional and services intervention for the people with dual diagnosis in the United Kingdom will be reviewed. Since social service is also a partner in these service deliveries, related research will also be searched. Perspectives The perspectives and experiences of the people with dual diagnosis and their caregivers as well as those of the mental health professionals will also be sought from the literature, and they can serve as guide to assessment of adequacy of mental health services. Strategy for Literature Review Inclusion and exclusion criteria enable the researcher to identify literature which addresses the research questions. The developed criteria would be guided by the wording of the focus question. Inclusion Criteria Inclusion criteria for each article reviewed were answers to the following questions: 1. Was the article a valid research article? 2. Did the article study the problem of dual diagnosis in any client groups, with no restrictions on race or gender, mental health diagnosis, or substance of abuse? 3. Did the article’s study include mental health services for the people with dual diagnosis? 4. Did the article deal with awareness of mental health service professionals regarding dual diagnosis in the UK? 5. Did the article deal with mental health professionals' or patients’ perspectives in terms of dual diagnosis? 6. Did the study deal with barriers of service access and service delivery in clients with dual diagnosis? 7. Was the study based on associated social services that are mandatory in appropriate service delivery for dual diagnosis? 8. Was the article published within the past 10 years? 9. Did the article have some identification with mental health services provided for dual diagnosis? 10. Did the article deal with mental health services and its adequacy for people with dual diagnosis in the UK? Exclusion Criteria Each article should answer “yes” to all of these questions, the only exception being question 4, where either patient or mental health professional perspectives will be acceptable. Based on these criteria, six main latest research articles were chosen out of about 257 initial articles based on the criteria described above. Resources Gray literature such as lay web publications and quality newspaper articles were kept outside the search. It was also decided that apart from academic journal articles, the ready sources of reference books from the university library will be utilised (Hart, 2003, 110-134). This author conducted a literature search across databases to review related literature and utilize them for this project. The websites accessed for information included: CINHAL, Medline, Pubmed and the Google Scholar internet search engine. Moreover MEDLINE, EMBASE, and CINAHL and Cochrane databases were included to identify relevant literature. HighWire Press was also searched. These sites were accessed through online registration in the respective websites (Polit and Beck, 2005, 31-45.) The search for relevant literature began with identification of the key words. These words were coined from the rationale and the focus question of this particular research. Then through application of Boolean logic, some combinations of key words were decided to be searched (Horsburgh, 2003, 307-312). The initial search was conducted based on the abstracts of the prospective articles, and if an article could be narrowed down with presence of the combination key word terminology, a detailed search was undertaken on that article (Horton, 1995, 985-987). Search Terms Library/Titles Computer Databases Mental health services + dual diagnosis No results 347 Results Needs for service users + illicit substance abuse +mental illness No results 31 results Mental health professionals + dual diagnosis + available services No results 17 results Dual diagnosis + service needs + available mental health services No results 2 results Mental health professional attitudes + Perspectives of patients with dual diagnosis + service needs + available mental health services No results No results Table 2: Key word combination and search results Few text books were found out to have particular chapters on mental health services for individuals with dual diagnosis. (Popay et al, 1998, 341-351). Out of 45 text books accessed only 4 were chosen on the basis of availability. All of these resulted in the access of about 397 articles. A more focused search was conducted through the combination of key words with use of Boolean adjuncts “and”, “or”, or “not.” The key words in the search included “mental”, “health”, “services”, “mental health services”, “mental health professionals”, “service delivery”, “needs”, “needs assessment”, “service users”, “clinical trials”, "dual diagnosis", "serious mental disease", "serious mental illness", "illicit substance abuse," "addiction", "substance use", and "drug abuse", “needs of service users”, “fully meeting”, “services framework”, “available mental health services”, “patient beliefs”, “barriers to communication”, “mental health professional perspectives”, “patient perspectives”, “preventive mental health services”. Validity in research terminology refers to the accuracy of the data and the findings and this was one of the aims of this study. Reliability is related to the proof of consistency and dependability of the data. This researcher used a computer programme to assess the quality of the studies (Russell and Gregory, 2003, 36-40). Literature Review Chapter 1 Holland (1998) indicates that dual diagnosis describes co-existing mental illnesses and substance misuse. He further added that traditional substance abuse treatment approaches must be modified and integrated within traditional mental health treatment. McCrone et al. (2000) compared the service costs of dual diagnosis management as opposed to people with mental illnesses without substance abuse. This combined qualitative interview study -quantitative cost assessment study found out that most of the dual diagnosis clients used community psychiatric nurses, emergency clinic, and inpatient care representing higher service costs that nondual diagnosis patients. (McCrone et al., 2000, 446-472). Manley (2005) has discussed the role of DOH good practice implementation guidelines on dual diagnosis. These guidelines clearly outline the framework of service for people with mental health problems who are problem drinkers or problematically habitual drug users. Hughes et al. (2008) conducted a radomised controlled trial among mental health workers in the UK. The researchers recruited 79 case managers from different community mental health teams in South London. The authors were able to draw a conclusion that knowledge and training about dual diagnosis management were deficient in mental health workers, and brief training course in dual diagnosis intervention may lead to the improvement of attitudes towards these patients, although it is clear that further research is needed (Hughes et al., 2008, 12). Abou-Saleh (2004), in his review article, has pointed out recent developments in the UK Government Policy which has highlighted the unmet needs of the clients with dual diagnosis. The author reports community based surveys in both USA and UK, which report a high rate of comorbity in the range of 22% to 30%. Graham et al. (2001) attempted to determine the extent and impact of substance abuse. In this qualitative study, the authors conducted a large scale survey to determine the prevalence of substance abuse problems among clients with severe mental illnesses. The results indicated that out of a sample of 3079 clients, 1369 had severe mental illnesses, and 245 of them had problem drinking or problems with drug abuse. The authors concluded that despite available services, the prevalence of dual diagnosis is high (Graham et al., 2001, 448-455). Crome and Myton (2004) reviewed evidence regarding prevalence of dual diagnosis and the provision of current advanced drug therapy in these patients. The authors referred to the study of Crawford et al (2003) where population based longitudinal studies have consistently demonstrated high prevalence of substance use in patients with major psychiatric illnesses (Crawford, Clancy, & Crome, 2003, S1-S74). Coulthard et al. (2002) reported a national comorbidity study where there was demonstrable 4% dependence on any substance with 3% of these individuals reporting cannabis use (Coulthard et al., 2002). Comorbidity leads to frequent occurrences of mental disorders, longer stays in the hospital, homelessness, isolation and alienation from the social support groups. The authors referred to the study of Hunt et al. (2002) who indicated that, with appropriate care within this framework, some psychiatric patients with a dual diagnosis would achieve stability rapidly. As indicated by Tyrer & Weaver (2004), a sensitive anticipatory action focusing on medication review against relapse prevention can be very effective. However, although incorporated within the model of service delivery framework, local arrangements are important to deliver it effectively, where each of the components of the framework must work in conjunction (Crome and Myton, 2004, 413-424). Graham et al. (2003) points to the challenges faced by the UK mental health services as to how they should meet the needs of people with dual diagnosis. The authors focused on a two-stage training package that was offered to the primary care mental health teams and the inpatient services. These frameworks are comparatively newer in the UK, and therefore, the authors recommend that although there is a need for continuity of care and integration, any service model must be evaluated before its implementation (Graham et al., 2003, 183-186). Reflection on Practice Literature reviews are becoming more and more important in health and social care. While doing this literature review, this author remembers coming across a large number of articles (Jensen and Allen, 1996, 553-560). While reflecting on this literature, this author was able to deduce that many articles did not meet the methodological parameters and the framework which was chosen for the review, and it was very easy to be swayed away from the focus questions (Knipschild, 1994, 719-721). To be able to do this appropriately and to remain within the framework, regular and detailed notes of even irrelevant studies were needed to be taken (Law, 2004, 54-66) In the beginning, it was natural to start trusting in any information given by a particular literature. However, as this process progressed, it was found that it would be very important for this author to retrieve all available evidence on the topic and start reviewing them critically so that an overall picture of what is known about the topic is achieved (Littleton et al, 2004, 892-908). Accessing the databases mentioned above could have been a problem if the university library would not have facilitated access of the above databases through Athens and Ovid online databases. The most robust articles were chosen to be reviewed in this extended literature review with a nonbiased enhancement of extension of enquiry (Jones, 2004, 271-278). Conducting a literature review would contribute to the development of analytic and critical evaluative skills through identification of strengths, relevance, and limitations of the study in establishing its reliability and validity to the posed question (Montori et al., 2004, 7482). There are limitations in this literature review. Moreover, literature opposing the current concept of mental health nursing management of clients with dual diagnosis is lacking. Some resources are not available. Due to the lack in statistical knowledge, the data culling and analysis became purely qualitative, which may fail to provide concrete evidence. However, despite these limitations, this review could result in suggestions for improvement in nursing guidelines. Implications and Recommendations for Practice From this literature review, the evidence may lead to the following recommendations which may lead to the development of a guideline for practice in mental health nursing for patients with dual diagnosis, with the aim of providing a better and more efficient care. Since the prevalence of this condition is on the rise, there is a need for comprehensive framework for services. Knowledge and skills of mental health professionals must be increased through dissemination of findings from new researches in this area, since training seems to improve the care. The model of service should be within the service framework so that access to services is encouraged. There must be close communication between the different stakeholders involved in service delivery so that the social care aspects of these clients are not affected. Moreover, outreach programmes must be developed where the existing community mental health services may be used for the prevention of relapse and improvement of motivations. New models have been developed within the mental health system to integrate substance abuse treatment for the dually diagnosed, including the Assertive Community Treatment Team model, the Integrated Treatment model, the Stages of Treatment model, and the Motivation Based Dual Diagnosis Treatment model. The Integrated Treatment model emphasises case-management care in an integrated manner, which is based on the premise that there are parallels between the mental disorders and substance abuse. The assertive outreach programme is a stage-wise, cognitive-behavioral substance abuse treatment integrated into comprehensive community mental health services, which include outreach, case management, and medications. The model incorporates five stages of dual-diagnosis treatment: engagement, persuasion, coercion, relapse prevention, and action. Dual diagnosis is on the rise. Despite different definitions, it has been agreed upon that coexisting substance abuse and mental illness can have serious social and economic implications. There is still a paucity of research in this area in the UK, and despite the perceived need for further research and evidence, there is already a need-based mental health service framework for clients with dual diagnosis. If appropriately trained and educated, mental health nurses can contribute to the effectiveness of such services. Reference List Abou-Saleh, MT., (2004). Dual diagnosis: management within a psychosocial context. Advan. Psychiatr. Treat.; 10: 352 - 360. Appleby, L., Shaw, J., Sherratt, J., Et Al (2001) Safety First. Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Department of Health. 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